The Affordable Health Care Act annual wellness visits: the effectiveness of a nurse-run clinic in promoting adherence to mammogram and colonoscopy recommendations

Increasing Medicare Annual Wellness Visit Utilization: An RN-Led Model of Care Pilot

Annual wellness visits (AWVs) are an important component of primary care as they provide preventive services and an opportunity to identify safety and health risk factors for Medicare beneficiaries. However, primary care practices are facing unprecedented demands with high patient volumes, multimorbidity, a rapidly growing aging population, and primary care provider (PCP) shortages. RN-led models of care are increasingly recognized as a major key to providing quality care while relieving PCP demands. This article describes the implementation of an RN-led model of care pilot in an urban family practice to increase Medicare AWV completion and alleviate PCP burden.

Are Medicare wellness visits improving outcomes?

BACKGROUND

As the largest and unhealthiest population in American history enrolls as Medicare beneficiaries, it is vital for primary care providers to understand how to maximize Medicare wellness provisions. The Baby Boomer population has been documented to have the highest chronic disease prevalence related to preventable lifestyle behaviors. Perpetual unhealthy lifestyle behaviors associated with chronic disease prevalence are detrimental to life quality and the American Medicare resource structure. Since 2011, the Affordable Care Act provisions have included free wellness visits designed to prevent disease for Medicare beneficiaries, who continue to grossly underuse these services.

OBJECTIVES

This systematic review was conducted to evaluate the quality, level, and strength of evidence regarding Medicare wellness service efficacy on related health outcomes.

DATA SOURCES

The methodology adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for selection of 21 research-based articles included in the analysis. Results from the 21 eligible studies revealed low research quality and vigor; therefore, lacking causality and generalizability of medicare wellness visit (MWV) efficacy on health promotion outcomes.

CONCLUSIONS

The evidence is focused on how MWVs are affecting preventive care utilization instead of patient health outcomes. In the interest of reducing chronic disease prevalence and the economic burden on our health care system, it is important to understand how these services affect health promotion outcomes.

IMPLICATIONS FOR PRACTICE

The results of this systematic literature review substantiate the need for primary care providers to study MWV efficacy on health promotion outcomes for the Medicare population.

Effect of periodic health exam on provider management of preventive services

RATIONALE AND OBJECTIVE

To evaluate the relationship between receipt of annual physicals and the receipt of provider recommendation for preventive services, during a period when Medicare did not cover annual physicals (before 2011).

METHODS

Electronic medical records of patients aged 65 years and older from a US health care system were extracted for the 2001 to 2007 period. A fixed-effects logistic model was used to assess the relationship between receipt of periodic health examination (PHE) and receipt of provider recommendation for mammogram screening for 6466 female Medicare beneficiaries. Logistic regression models were used to assess the relationship between receipt of PHE and receipt of provider recommendation for colonoscopy screening and pneumococcal vaccination for 10 318 Medicare beneficiaries. Nine primary care providers from the network were also interviewed, selected by random sampling stratified by care model.

RESULTS

Electronic medical record analyses suggest that patients with a PHE were more likely to obtain provider recommendations for mammogram screening (OR = 2.17, P < 0.0001), colonoscopy screening (OR = 1.54, P < 0.0001), and pneumococcal vaccination (OR = 1.10, P < 0.0001). Providers suggested that prevention care quality improves with the PHE because certain screening measures (eg, skin cancer screening, breast exam) would be neglected without it, and healthy patients could miss recommended preventive services entirely. Without the PHE, some providers reported having tried to incorporate discussions of preventive services by scheduling more frequent follow-up chronic care visits than they would have otherwise, and some routinely charged Medicare for a more complex follow-up visit than they would have charged without the preventive service discussions.

CONCLUSION

Periodic health examination is important in connecting patients to recommended preventive services. Provider interviews suggested that, indirectly, Medicare ended up paying for the PHE via greater frequency of follow-up visits or higher visit charges from providers integrating the services with other visits.

Multilevel Interventions To Address Health Disparities Show Promise In Improving Population Health

Multilevel interventions are those that affect at least two levels of influence-for example, the patient and the health care provider. They can be experimental designs or natural experiments caused by changes in policy, such as the implementation of the Affordable Care Act or local policies. Measuring the effects of multilevel interventions is challenging, because they allow for interaction among levels, and the impact of each intervention must be assessed and translated into practice. We discuss how two projects from the National Institutes of Health's Centers for Population Health and Health Disparities used multilevel interventions to reduce health disparities. The interventions, which focused on the uptake of the human papillomavirus vaccine and community-level dietary change, had mixed results. The design and implementation of multilevel interventions are facilitated by input from the community, and more advanced methods and measures are needed to evaluate the impact of the various levels and components of such interventions.

The Medicare Annual Wellness Visit

The Medicare Annual Wellness Visit is an annual preventive health benefit, which was created in 2011 as part of the Patient Protection and Affordable Care Act. The visit provides an opportunity for clinicians to review preventive health recommendations and screen for geriatric syndromes. In this article, the authors review the requirements of the Annual Wellness Visit, discuss ways to use the Annual Wellness Visit to improve the care of geriatric patients, and provide suggestions for how to incorporate this benefit into a busy clinic.

Assessing pharmacist-led annual wellness visits: Interventions made and patient and physician satisfaction

OBJECTIVES

To quantify the nature and frequency of interventions made by pharmacists during a Medicare annual wellness visit (AWV), to determine the association between the number of medications taken and the interventions made, and to assess patient and physician satisfaction with pharmacist-led AWVs.

SETTING

Large, teaching, multidisciplinary family medicine practice in North Carolina.

PRACTICE DESCRIPTION

Mountain Area Health Education Center (MAHEC) is a large academic practice that serves rural, western North Carolina. There is a heavy emphasis on team-based care.

PRACTICE INNOVATION

Pharmacist-led AWV.

EVALUATION

Between April 2012 and January 2013, the following were evaluated for 69 patients: the nature and frequency of interventions made, the association between the number of medications taken and the interventions made, and patient and physician satisfaction scores.

RESULTS

A total of 247 medication-related interventions and 342 nonmedication interventions were made during the pharmacist-led AWVs. The majority of medication interventions (69.6%) involved correcting medication list discrepancies. The number of medications taken was positively associated with the total number of medication interventions (r = 0.37, P <0.01). On a 5-point Likert scale, patients strongly agreed that the AWV is important for their overall health (mean 4.8, median 5) and that they would like to see the same provider next year (mean 4.8, median 5). Physicians strongly disagreed that they would prefer to do the visit themselves (mean 1.5, median 1) and strongly agreed that their patients benefited from a pharmacist-led AWV (mean 5, median 4.9).

CONCLUSION

Pharmacists addressed both medication and nonmedication interventions during AWVs. Patients taking a greater number of medications required more medication interventions than patients taking fewer medications. Patients and physicians reported satisfaction with the pharmacist-led AWV.

The Affordable Care Act, Accountable Care Organizations, and Mental Health Care for Older Adults: Implications and Opportunities

The Patient Protection and Affordable Care Act (ACA) represents the most significant legislative change in the United States health care system in nearly half a century. Key elements of the ACA include reforms aimed at addressing high-cost, complex, vulnerable patient populations. Older adults with mental health disorders are a rapidly growing segment of the population and are among the most challenging subgroups within health care, and they account for a disproportionate amount of costs. What does the ACA mean for geriatric mental health? We address this question by highlighting opportunities for reaching older adults with mental health disorders by leveraging the diverse elements of the ACA. We describe nine relevant initiatives: (1) accountable care organizations, (2) patient-centered medical homes, (3) Medicaid-financed specialty health homes, (4) hospital readmission and health care transitions initiatives, (5) Medicare annual wellness visit, (6) quality standards and associated incentives, (7) support for health information technology and telehealth, (8) Independence at Home and 1915(i) State Plan Home and Community-Based Services program, and (9) Medicare-Medicaid Coordination Office, Center for Medicare and Medicaid Innovation, and the Patient-Centered Outcomes Research Institute. We also consider potential challenges to full implementation of the ACA and discuss novel solutions for advancing geriatric mental health in the context of projected workforce shortages and the opportunities afforded by the ACA.